ATI Acute Care Final exam 2022/2023 with 100% correct answers

A nurse is on a medical-surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? A. Client who has an ulceration of the right heel whose blood ...

A nurse is on a medical-surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? A. Client who has an ulceration of the right heel whose blood glucose is 300 mg/dL B. Client who reports right calf pain and shortness of breath C. Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization D. Client who has dark red coloration of left toes and absent pedal pulse correct answerB. Client who reports right calf pain and shortness of breath A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse plan to take? (Select all that apply.) A. Induce vomiting. B. Instill activated charcoal. C. Perform a gastric lavage with aspiration. D. Administer syrup of ipecac. E. Infuse IV fluids correct answerB. Instill activated charcoal. C. Perform a gastric lavage with aspiration. E. Infuse IV fluids A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following are appropriate actions by the nurse? (Select all that apply.) A. Remove wet clothing. B. Maintain normal room temperature. C. Apply warm blankets. D. Apply a heat lamp. E. Infuse warmed IV fluids. correct answerA. Remove wet clothing. C. Apply warm blankets. D. Apply a heat lamp. E. Infuse warmed IV fluids A nurse in the emergency department is assessing a client who is unresponsive. The client's partner states, "He was pulling weeds in the yard and dropped to the ground." Which of the following techniques should the nurse use to open the client's airway? A. Head-tilt, chin-lift B. Modified jaw thrust C. Hyperextension of the head D. Flexion of the head correct answerA. Head-tilt, chin-lift A nurse is reviewing the common emergency management protocol for clients who have asystole. Which of the following actions should the nurse plan to take during this cardiac emergency? A. Perform defibrillation B. Prepare for transcutaneous pacing C. Administer IV epinephrine (Adrenaline). D. Elevate the client's lower extremities correct answerC. Administer IV epinephrine (Adrenaline). A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply) A. Use the Glasgow Coma Scale when assessing the client B. Assist the client to a supine position C. Administer an opioid medication D. Encourage the client to increase fluid intake E. Instruct the client to perform deep breathing and coughing exercises correct answerB. Assist the client to a supine position C. Administer an opioid medication D. Encourage the client to increase fluid intake A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension correct answerB. Infection a nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoke to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? A. E2 + V3 + M5 = 10 B. E3 + V4 + M4 = 11 C. E4 + V5 + M6 = 15 D. E2 + V2 + M4 = 8 correct answerB. E3 + V4 + M4 = 11 A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast dye. Which of the following statements by the client should the nurse report to the provider? (Select all that apply.) A. "I think I might be pregnant." B. "I take warfarin." C. "I take antihypertensive medication." D. "I am allergic to shrimp." E. "I ate a light breakfast this morning." correct answerA. "I think I might be pregnant." B. "I take warfarin." D. "I am allergic to shrimp." E. "I ate a light breakfast this morning." A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? A. "Do not wash your hair the morning of the procedure." B. "Try to stay awake most of the night prior to the procedure." C. "The procedure will take approximately 15 minutes." D. "You will need to lie flat for 4 hours after the procedure." correct answerB. "Try to stay awake most of the night prior to the procedure." A nurse is caring for a client who displays manifestations of stage III Parkinson's disease. Which of the following actions should the nurse include? A. Recommend a community support group B. Integrate a daily exercise routine C. Provide a walker for ambulation D. Consult with dietitian correct answerC. Provide a walker for ambulation A nurse is developing a plan of care for the nutritional needs of a client who has stage IV Parkinson's disease. Which actions should the nurse include? (Select all that apply) A. Provide three large balanced meals B. Record diet and fluid intake C. Document weight every other week D. Offer cold fluids such as milkshakes E. Offer nutritional supplements between meals correct answerB. Record diet and fluid intake D. Offer cold fluids such as milkshakes E. Offer nutritional supplements between meals A nurse is reinforcing teaching with a client who has Parkinson's disease and has received a prescription for bromocriptine (Parlodel). Which of the following instructions should the nurse include in the teaching?